JIMANI, Haiti -- Editor's Note: KSAT.com has attempted to retain the integrity of Dr. Curiel's original content, with only minor changes for spelling, punctuation and grammar.

January 31, 2010 I text Krista Keachy who is still at the hospital in Jimaní, asking her for updates on some of my patient updates. She texts back:

"Today has been a good day: at least 30 patients on helicopters to definitive care, 10 to the USS Comfort, others to Sacre Coeur in Milo, Haiti. All the spines [injuries], all the peds [pediatric patients], all the infected open fractures, and one high risk pregnancy. Another helicopter is supposedly coming. We also had our first delivery, twins! I am working on getting transportation for the family members of the spines so they can be united."

Social work, like Krista was doing trying to unite family members, was another big function of ours there. There was no good social work system in place during our stay. Many patients were asking to help us find relatives. Any Haitian who left the Dominican Republic to return to Haiti and who didn’t have travel documents such as passports (which meant almost all of them) would be very unlikely to get back to us. So if they tried to leave to search for a family member in Haiti, they would not be able to get back to any family left in our facility or elsewhere in the Dominican Republic. It was a terrible catch-22 for a lot of them.

I get more follow up. The woman that I sent up to the Intensive Care Unit a few days ago with the rapidly spreading foot infection has stabilized on antibiotics and was transferred back to the orphanage.

Shirley, with the need for the amputation of her left foot, has been airlifted to the USS Comfort, but we lose her from there.

Rita, with the maggots growing in her gaping head wound, was taken to the operating room by a plastic surgeon who had arrived the day before. He carefully debrided the wound and closed it shut for good with a skin flap. Rita calls Ruth on her cell phone from her mattress in room 7 at the orphanage to give her the good news herself!

A man who had panicked and jumped off the second floor balcony during one of the strong tremors last week had burst a vertebra (spinal bone) in the jump. He had been airlifted out then. We find out that he had survived being buried in the original earthquake in Port-au-Prince, made his way to us in Jimaní, but had died during the helicopter airlift after his jump. He is one of many patients dying far from Port-au-Prince after the quake. Aside from the tragedy of the needless death, how many others are there like this? Should this be counted as a quake death? What about the others who died or will die of injuries from the quake at other times and in other places?

Krista texts us that staffing is very thin and that patients aren’t getting adequate attention down at the orphanage. Ruth calls Dale Betterton to apprise him.

Ruth gets a phone call from Dr. Jean-Claude Ulysse, the surgeon who works at the hospital that she helps run in Mirebalais, Haiti. Mirebalais, in the Artibonite Valley, was spared serious earthquake damage, but is inundated with patients as it is an hour closer to Port-au-Prince than Cange, where Paul Farmer has founded a Partners in Health hospital. Paul Farmer and Ruth were classmates at Harvard Medical School and have shared a common interest in Haiti over the years. Jean-Claude is currently in Port-au-Prince, living with his wife in a car outside his house as the house was too badly damaged in the earthquake. When he arranges his affairs he will get back to Mirebalais.

Krista and I are texting about how to manage a patient who has developed a new fever. Apparently there are no infectious disease specialists there now. Ruth and I understand that we have to start extricating ourselves emotionally from daily operations in Jimaní but it is difficult.

January 30, 2010 We take a bus back to Santo Domingo to catch our flight back home. On the bus we discuss final logistical issues that were not completely resolved, such as which patients were optimal transfer candidates to Fond Parisien, and how to organize medical activities between the various medical teams in the Buen Samaritano medical complex. We discuss strategies to keep operations moving forward without running afoul of local politics, both Dominican and Haitian.

We discuss the odd personality types that we had seen, such as the earnest, but misguided physician. For example, one foreign physician seemed not to have a clear role but simply floated around and kibitzed others at work, seemingly oblivious to the reality of things. I recall her asking me in horror why I didn’t have the medical records of a teenage boy who arrived seemingly from nowhere in a near-comatose state, so that we could begin to sort out his medical problems. After rapid discussions with Ian the emergency room attending physician, Steve Younger the anesthesiologist and Chris Madden the neurosurgeon, we conclude that we can’t really figure out what is going on with the boy. The foreign doctor then takes my stethoscope from around my neck, listens to the patient’s heart and lungs and pronounces very solemnly, “At least I can say that he has a heart beat and is breathing.” She looks up to make sure that we have processed this important new medical information. I just want her tossed out, stat. The others are trying not to laugh. We get back to work on the boy.

Then there are the Good Samaritans. For example, there were a number of foreigners in Jimaní who came on their own and paid their own way to do whatever they could. I recall a mother-daughter team from Spain. They were not affiliated with any agency but simply came to help. The mother had approached Ruth asking for money to go to town to buy things. Ruth was tired of being scammed for money, as we had a lot of cash to buy supplies. But we needed staples such as soap and shampoo for the patients, and sandals so that injured patients could try to undergo some physical therapy in the very rocky courtyard. Ruth chanced it, gave the mother $200 and was relieved when she came back a few hours later with all the requested supplies including a huge load of flip flops that we quickly distributed.

Dale and Dorothy Betterton are there because they are well-equipped to help. They founded International Medical Associates (IMA) as an international health relief agency around 2000. IMA spent 2 years helping in post-Katrina New Orleans and had operations in other parts of the world. Dale was the chief of overall international operations at Buen Samaritano, and was to whom we reported. He was using not only his IMA funds, but his personal funds from the sale of his home to fund operations.

We arrive in San Antonio shortly before midnight. Marvin Forland, an emeritus professor at our medical school, and his wife Elly insist on picking us up at the airport. We are very grateful for the ride. Marvin now works in Ruth’s Center for Medical Humanities and Ethics, which is underwriting our efforts in Jimaní, and raising additional funds for earthquake relief.

When we left Jimaní it was around 90 degrees. Now it is 35 degrees. We are also undergoing some culture shock.

January 29, 2010 On the bus ride in to Jimaní today, we discuss some interesting cultural issues that have arisen. Many patients have external fixation devices (“ex fixes”, as we call them). These are the rods and bolts drilled into their bones above and below the major unstable fractures to allow a chance for broken bones to heal in alignment. The metal hardware sticks through the skin at many odd angles. The base of each pin or screw as it protrudes through the skin is a weak point where infection can get into deeper tissues including the bone itself. Some orthopedic surgeons appear fond of putting bandages around the ex fix bases and wrapping more dressing over the external hardware to try to fend off infections. Other surgeons appear content to leave the ex fixes unwrapped, and keep the surrounding skin clean but uncovered. In Haitian culture, it is common to wrap a bandage around a sore spot, especially a sore back. As the orthopedic surgeons and wound team personnel turn over, the style of caring for the ex fixes varies. Some patients are upset to find that their ex fixes, previously wrapped and bandaged as a Haitian could typically expect for a sore spot, are now uncovered. They want them wrapped again, to help with pain control.

Another Haitian cultural belief is that a mother’s milk will sour after a major emotional shock, causing harm to her baby. Thus, some Haitian mothers appear to have stopped breast feeding after the earthquake, and instead have switched to infant formula. Mother’s milk is usually best as the formula can easily get contaminated with bacteria and cause potentially severe and dangerous diarrhea in the baby. Formula is also typically not as good for the baby’s immune system as mother’s milk. Ruth is working on convincing mothers to go back to breast feeding and to get them to believe that their milk has not soured and will not harm the baby.

My wife says that I need to go to the Intensive Care Unit to see a patient whose neurological examination is compatible with a voodoo curse. Of course, I have to go to see!

I begin rounds on ward “C” with a new team of nurses, the prior team having wrapped up their tour of duty the day before. The Hospital census is down to under 230 patients we are told. The tent city is down to about 6 families and I note an empty spot or two in the previously packed hall that we have been using as a ward of sorts, so clearly the patient numbers are down. After an hour of relatively uneventful rounds I suddenly see Carlos Educar, the man we initially met us at the airport in Santo Domingo last week who drove us out here to Jimaní. He is about to go to Fond Parisien just across the Haitian border, the place that we have been sending the majority of patients that we are transferring out. I make a snap decision to hitch a ride to see it. We still don’t have good intelligence from the prior trips to determine exactly what conditions are like there and to understand which patients would be the best candidates for transfer There. He says he can get me there and back in about 45 minutes. Perfect. Then I remember that I don’t have my passport on me. I decide to chance it, figuring border security will be lax enough, or I’ll be able to talk my way over and back. He says that no one has checked any passports crossing the border in either direction, I run up to the hospital to find Chris Madden, the neurosurgeon, but can’t. I find Krista Keachie, a neurosurgery intern. She asks to come. Moments later Krista and I are on our way with Carlos. We get stuck behind a huge truck convoy of materials hading to Port-au-Prince, which is only about 40 miles away. We are detained at the border for an hour for some paperwork issues related to the supplies we are also carrying. No one asks to see our passports. Krista doesn’t have hers, either.

We pass open white rock quarries that are being worked by hand. People are fishing in Lago Enriquillo, which borders the road out to Fond Parisien on our right. The lake is beautiful and the water looks clear and unpolluted except for small amounts of garbage floating near the shore. We pass through a few small settlements that are densely populated. Business at the local market is brisk. There are beauty shops, billiards halls and small stores of various kinds. Life looks completely normal to me. There was no major earthquake damage here. We finally arrive at Fond Parisien two hours after leaving Buen Samaritano Hospital on what is usually a 20 minute trip. We find a large complex of yellow buildings on nice grounds, with a large number of assorted tents in front and on the left side as we approach. We put our heads into their operating rooms and see two simultaneous surgeries ongoing, one a complex wound cleaning under anesthesia, with exposed bone, and the other is a placement of external fixation devices. All looks in order and efficient. The pharmacy looks good but in need of medicines. We meet the overall director, Dr. Hilliary Cremner from Harvard Medical School and Dr. Christian from Yale. They give us a good description of their facilities, and what kinds of patients they can and cannot accept. Needless to say, what they tell us contradicts many of our prior instructions. We decide to have one sole telephone of contact for each facility. They request 500 pairs of crutches, as many 30 gallon plastic trash bags as we can find, and lots of food. I want to try to find some of the patients we have previously transferred to get their opinion of this place versus our facility, but we decide that we should get back, as we have been gone much longer than we had planned.

Back at the orphanage I share the Fond Parisien intelligence with Jim Webb, the Canadian emergency medical technician who has been done such a fabulous job of coordinating transfers and attending to other logistical issues in the orphanage. I notice that there is now a line of patients finally getting X-rays! At last we can start getting radiographic data on what injuries our patients have, and can see the progress with the ex fixes. I help transport some patients to get X-rays and round on some patients and put out the usual fires. We take a young boy back whose right forearm has two curves in it where it had been broken. Now we will get a chance to see what is going on so that the surgeons can fix it. It was stable and not painful before, so this injury had been put on the back burner. Another patient had a crush injury to the left foot and had significant pain on walking. The orthopedic surgeons suspected a broken bone in the foot, and the X-ray now confirms the diagnosis and identifies the specifics. A 13 year-old girl in the tent city has had moderate deafness, a new crossed right eye and trouble with comprehending speech since a head injury in the earthquake. She will have to continue to wait until we can get a CAT scanner, but at least she is not in significant pain and is stable.

I get a chance to talk to a boy of 14, René. He was on the bottom floor of a 3-story apartment when it collapsed. His two brothers and sister were killed. He lay there buried for 3 days with their dead bodies crushed on top of him before he was pulled out.

I see Shirley, the woman with the left femur fracture whose bones are dying. She has had her ex fix revised by Bob Hoffman, the orthopedic surgeon from California who has been working with us for the past few days. She has now definitively refused the amputation and will take her chances. Bob greatly impressed me with his work ethic and bed side manner. Whereas most of the surgeons were in a hurry to dash off to do more procedures (not necessarily a bad thing), Bob had stayed with us at Shirley’s bed side the day that Ruth walked her through the medical issues that meant we would have to amputate her foot.

Rita is a woman in room 7 on “C” ward who was hysterical the day that I got there. Her screams and wails greatly upset the other patients packed into the same tiny ward room. All the women in room 7 have severe leg injuries, generally meaning smashed leg bones, and all are sitting on the mattresses on the floor as they cannot walk. All have ex fixes jutting through their skin at various angles. It turns out that Rita had been trapped under her house for 3 days after the earthquake and that a huge chuck of her scalp on the crown of her head had been gouged out. While she lay buried under the building, flies had laid eggs in her open wound, which had then become packed with big, wriggling maggots. We had been taking her back to the procedure room twice a day to give her anesthesia to put her lightly to sleep to debride the maggots out, but for days there were always more maggots just a few hours later. Two days ago, Ruth and I had been rounding together, and had found her sitting up on her mattress in this room in the late afternoon, singing a tuneless song, babbling about going to Montreal to see Celine Dion and pronouncing that she was in her own galaxy. This was a common side effect of the ketamine we were using for anesthesia. Ketamine is a fabulous anesthetic, but is little used on people in the US as it can cause “trips” like Rita was having. Trips can be very unpleasant, like a bad acid trip. Rita was greatly enjoying her trip, but her roommates wished she would just quiet down. To help prevent bad trips, patients were getting a little morphine and Versed with the ketamine. I had seen quite many and varied ketamine reactions, but nothing I would call a bad trip. I asked Steve Younger the anesthesiologist if he had seen any bad trips. In all the hundreds of patients, he had seen two mildly bad ones in which they had to give additional sedation.

Towards evening I had some spare time so I decided to make bonbon rounds. There were a few patients requesting extra pain medications as they had been to surgery earlier that day. I put some narcotic pain medicines in another bag to dispense as I was making my way along with the bags of candies. It was another of those surreal moments: a bag of candy in one hand, a bag of narcotics in the other and working my way through an open floor space with dozens of gravely wounded patients on the floor lying on thin mattresses. Late in the course of these rounds I stop in to room 7 and am chatting with the ladies there. Rite had calmed down in the past two days as most of her maggots had been cleaned out, greatly improving morale and the general tenor in the room. The patients ask me how it is that I speak Haitian Creole. I tell them “Dr. Ruth, li madam mwen” (Dr. Ruth is my wife). They go completely nuts. Dr. Ruth is the smash hit among the Haitians because she speaks authentic Creole with no trace of an accent, whereas most of us that speak any Creole at all have strong American accents and massacre their mother tongue. My Creole rarely fails to incite gales of good-natured laughter from the patients, but they are very appreciative of my efforts. The Dr. Ruth connection is big news. My standing has just vaulted way up. They chatter on about how great Dr. Ruth is and how much good she has done them. Rita tells me Dr. Ruth has given her her telephone number so that she can be called back in the US. We keep the medical dossiers at each patient’s bed side. She shows me where Ruth has carefully and neatly written her cell phone number (and e-mail address) on the back of her medical dossier. Impressive. One by one all the other women proudly turn their medical dossiers over and show me where Dr. Ruth has written her cell phone number and e-mail address on the back of their dossiers, too. Needless to say, all these ladies will be calling to update us. What a fantastic idea. I leave smiling from ear to ear.

A nearly full moon hangs over the orphanage as I start to wrap things up just after 7 PM. I head back up to the main hospital from the orphanage to gather the last of the supplies I have brought for distribution to Fond Parisien. I get to the second floor just as Dale Betterton starts to give the daily report. With the renewed ability to transfer patients to other sites, the patient census is down to around 160. World Relief has just donated 138 beds so that patients can actually sleep in beds and not on mattresses right on the floor with the dust and dirt and insects. This is really big news. We have been worried that if we couldn’t get the patients off the floors before the next rainfall, we would have a potential disaster on our hands. Ruth had invented a nicely rhyming song in Creole that was an instant hit with the patients:

Lapli tombé Colchon mouyé Nou entravé

(The rain falls, your mattress gets wet, you’re up s**t creek). The kids loved it.

Bottled water has become an issue, being largely depleted in the Jimaní area. Security appears to be worsening again in that too many unauthorized people are on campus around meal times. Still, there are no serious threats and no violence known.

January 28, 2010 6:45 a.m.: We board the bus to take us to Jimaní from Senator Peguero’s house, where we have been getting dinner and sleeping. As usual, our bus scatters the chickens roaming the roads. Last night on the way out to the house our bus had a staring contest with a large black bull on the highway. We practically had to touch him with the front of the bus to get him to move away. We pass a large swamp that has been created in the past 4 years by the waters overflowing from Lago Enriquillo, one of two salty lakes on island of Hispaniola. The bottom of Lago Enriquillo at 120 feet below sea level is the lowest point in the Caribbean islands. In retrospect, underground fault movements may have caused the lake to flood, which could have been the slippage of the major fault lines that cross through her and down to Port-au-Prince, culminating in the earthquake.

The total medical complex census is down to around 230 patients or so, from over 300 a few days ago as we continue to send patients to Fond-Parisien just over the Haitian border.

Today I am heading ward “C”. The ward census is down to 31 patients plus family members. Most stable patients are now gone, except those with external fixators, which we are told cannot be accommodated at Fond-Parisien.

The wave of secondary problems that we have been expecting appears to be arriving. A patient who never complains told me on rounds today the she felt bad. She looks ill and feels hot. She is running a low grade temperature but there is nothing localizing in the history or physical exam. I order a fever work up and we continue with rounds. During the course of rounds, the wound care/dressing change team asks me to come look at some wounds that I have not seen previously. Several appear to be developing complications. One woman has a large wound near her ankle where she suffered a severe fracture of the lower leg. The bone is plainly showing. I call over an orthopedic surgeon who takes her to our procedure room for a better exam under anesthesia. To make a long story short, the bone has died and there is an infection brewing. He needs to do an amputation now, while it can still be done below the knee. If we wait and the infection spreads, he will have to amputate above the knee, making her mobility much worse. In the US, he would have been able to save the leg through a long and complex series of operations, but he doesn’t have that luxury here. We are all devastated. She otherwise had seemed so well, and she herself was expecting a full recovery. He wants to operate that very afternoon. Just imagine lying on your back in a hot, dusty room on a thin mattress, surrounded by many other patients, all with severely broken bones, all bristling with external fixation devices. Your home is destroyed, your husband killed. Your baby of 16 months is with your sister in Port-au-Prince in who-knows-what kind of conditions. You think that if you can at least wait it out, let the bones heal, get your external fixation devices out, and go back to Port-au-Prince, you can try to carry on. Now, in a few hours she will have to have her leg amputated, which for her will be a bolt out of the clear blue sky. My wife, Ruth, is fully fluent in Creole and well-versed in Haitian culture as she lived in Haiti until she was 14. We arrange for her to come talk to the patient at the bed side to try to break the news as best as we can. When Ruth gently led the patient through recent developments and what they meant for her foot, she started weeping and wailing. “This is more terrible than terrible,” the patient wails, She recounts all her losses and how things are going from worse to worse. Her tears flow freely. We are choked up as well. After 30 minutes of trying to comfort her, we had to move on, but we were all very rattled.

Later in the afternoon it was calm for a while so we make social rounds, passing out candy and soap to all patients and their families. This was a huge hit and met with many words of gratitude and many smiles. Even the adults were all smiles as we placed treats in their hands. Ruth said to me “when you get to where you have time to pass out Tootsie Rolls, it must be quieting down”.

I went back to check on the woman with the new fever and discover a second patient with a fever. She is 15 years old and looks chronically ill. Her blood work shows that her bone marrow is not making enough platelets or white blood cells. She is anemic, but everyone is anemic. We are worried about malaria or possibly AIDS and send more blood work off to check. Her earthquake trauma is a possible fractured pelvis. She has been lying here for over two weeks waiting for the X-rays to diagnose her specific injuries so that a treatment plan can be formulated. I hope that in the next day or so we can get her X-rays done and find out where she stands.

The woman with the fever from earlier is complaining of pain so I go to check. Her right foot, completely normal on rounds this morning, is now swollen up. Her white blood count comes back elevated at 14,000, consistent with an infection in her foot. She looks worse and is in a lot of pain. I arrange to get an IV started and to have her sent up to the ICU, as this could progress rapidly, and she will not get enough attention on our huge ward due to our limited staffing.

I pass room 5 on the way back and get pulled in by a family member to see another patient with a new problem. While I am sorting this out, a Haitian religious support team enter the room, a man and a woman each about 50 years old. They start preaching some Gospel in Creole. The 7 or 8 patients packed into this room are all quickly in the spirit. The two ministers or whatever exactly they are, start singing and the tune is quickly taken up by all the patients. It is a Haitian song that I don’t recognize, but is about salvation and redemption and getting through hard times. A very thin woman in her 70’s jumps to her feet and raises both hands as she sings along. She is smiling broadly. The people go on singing and the two ministers start talking very rapidly, both at the same time, about hard times and being strong and having faith. Everyone is raising their hands and smiling and clapping hands. I think back to Port-au-Prince and imagine buildings tumbling, clouds of dust rising, all these peoples’ homes being ground to dust and their being left with nothing, from the little they had to begin with. I think about countless family members killed in an instant. I think about all the new complications that we are starting to see here. This will be such a long and difficult journey for all of them. How can they be so strong and continue to have such strength after so many trials, the earthquake only being the latest? I have to turn away to choke back my tears.

A bus comes in the afternoon and we load a number of patients and family members fairly uneventfully and send them to Fond-Parisien. This transfer system seems to be improving as is the integration with all the various agencies who want to be in the transfer loop. Nonetheless, the requests for lists of information from government and relief agencies has been increased, and become something of a running joke among us. Ruth reports that in the past day or two she has been requested by various agencies to provide lists of: 1. Pregnant women 2. Psychiatric issues 3. Patients with symptoms of malaria 4. Potential domestic abuse. Another physician told me that the people who came to install a water purification system would not install it until they had a list not only of the numbers of patients but also of every patient’s name that might be served by the system. The pharmacy has medicines fairly neatly arranged by category, but the\ drugs are from all over the world, with many different brand names for the same drug, depending on where they came from. To get drugs, we just walk in, talk to the pharmacist and get our medicines dispensed into small plastic bags what we take back to the patient. Most patients now have small plastic bags with drugs like mild pain killers and antibiotics for their wound infections at the bed sides with instructions for them written on the plastic bags. They take their own drugs and we check periodically as we do not have sufficient staffing to give all the drugs our selves. Nonetheless, the pharmacists told me that he gotten a request to provide some agency with an Excel spreadsheet of every drug in the pharmacy, a record of who was getting them, and the quantities dispensed. We all agree that it would be fabulous to have detailed records of all these activities, but we are a volunteer force and only have the manpower than we do, with the expertise that we have and the time available that we have. Such luxuries will have to wait a bit longer. It sounds so simple for an outsider to ask, “Why can’t you just do such-and-such, to get this information?” It sounds easy to overcome these issues, but it simply is not. Ruth found a simple fix for most requests for lists of information. When asked to prepare a list of potential tuberculosis patients, she reflected for a few moments and said, “It will take about 6 hours for me to gather that information. I would be happy to get it for you if you come with me and watch as I collect it”. The requests for lists seem to have abated somewhat after that.

Chris Madden the neurosurgeon finds me and we head up to the main hospital. I need to talk to the ICU people and tell them that a patient is being transferred. There is no phone line between buildings so the easiest thing is just to walk over and talk to them. I immediately see an amazing sight: the X-ray machine is being used in the Intensive Care Unit! For inexplicable reasons, the X-ray machine showed up in the wee hours. It is put to instant use.

A new group of neurosurgeons has arrived so Chris wants to orient them. We head over to The Chapel, another building converted into a ward on the hospital grounds, along with The Tent and The Trailers, each a defined area that everyone knows. There are 8 patients in The Tent who are paralyzed from the waist down after severe spinal injuries and 2 that are paralyzed from the neck down. A single paralyzed patient has been airlifted out since we have arrived. All that the rest can do is lie there in the stifling heat and dust and wait to see where this all goes. I tell the paralyzed patients that the X-ray machine has arrived and that they will have their X-rays later that evening. All are extremely happy for the news, although we physicians know that the X-ray will do nothing to restore their dead limbs.

Security no longer is the big issue that it was several days ago. Security seemed to have deteriorated to its low point around January 24 or January 25. We were told that the guards would be increased and posted at strategic locations. I don’t know exactly what was done, but there is now order, calm and tranquility to the comings and goings of people on the medical grounds. I feel perfectly safe.

I find out that the patient with the acute abdomen recovered uneventfully and went back to the orphanage.

January 27, 2010 1 p.m.: Today I am in charge of ward “C” in the orphanage with a patient census of around 60. I meet my colleagues from ward “A” on their rounds and they ask about the man we sent up to the main hospital last night with the acute abdominal pain. I told them that last night the surgeons were considering taking him for emergency abdominal surgery for possible strangulated bowel. It does not look like appendicitis. It still could be typhoid. They decided to watch and give antibiotics. This morning he is the same, no better and no worse, and they are still holding off on the surgery. Yet another mystery ailment waiting for resolution.

I place an early call to the Dominican Rotary Club to see if I can get antibiotics, narcotics and IV fluids. We are starting to see some phantom limb pain, and don’t really have the right drugs to treat it, so I am trying to see if the Rotarians can bring us some. The head of the Santo Domingo chapter came to visit me last night late at the hospital after having driven for hours from Santo Domingo and then taking a motorcycle to complete the journey here. He gets a whirlwind tour of the hospital and orphanage and agreed with our immediate needs. He will work on getting our supply list filled.

Duties are again an endless series of interruptions, detours and tasks within tasks. I see the neurosurgeons and interrupt my current patient care to go see two patients with them. Later I see the orthopedic surgeons and we compare notes on who is going for surgery and who is not. The dentists have arrived and we have to clear a space for them, meaning moving dazed and confused patients from on poor location, to make way for the dentists, to another suboptimal location on the sidewalk. Around 10 a.m. I am told that a bus will come in the afternoon to take more stable patients to Fond Parisienne. I have to stop and organize a detail to start seeing who can go today. We had some issues yesterday with the Dominican authorities about transporting people across borders, but got them resolved fairly quickly. At 11:30 am., in the middle of evaluating fevers, open wounds, physical therapy issues, logistical issues and issues regarding where to put various patients, the bus suddenly materializes. I am told to drop everything and get all patients that can go, on the bus. At that point, I hadn’t even started checking to see who could go! Chaos quickly descends as everyone drops everything to try to get as many people as possible to get on the bus, an excellent opportunity for them to get back to Haiti. They can’t get back to Port-au-Prince yet, as there is no infrastructure for them, but at least this is a start. Over the next hour we eventually identify those able to go and start to load them on the bus. In another diversion, the Spanish Team has identified a diabetic with a dangerously high blood sugar of over 500 (100 is normal). We have to find IV tubing and insulin. That done, I go back to the bus transportation problem. The Dominican authorities want more paperwork checked first, which greatly slows progress. In the meanwhile, the bus has been loaded and all the patients, about 10 today with about 25 family members, are baking in the bus. Many phone calls and conversations are now swirling in Spanish and Creole about how to fix the issues. The new team of doctors and nurses, having arrived within the past few hours, are absorbing it all quietly. This is their trial by fire. “Closets to a war zone I have ever been” one physician leans over and confides to me.

3:30 p.m.: The acute phase of operations is clearly over. We are now starting to focus more on medical, psychosocial and logistical issues. For example, the mother of a patient asked us to check her blood pressure. We took it and it was borderline high. We asked to see her blood pressure medicine but didn’t recognize the name. When we looked it up, we discovered that it was a European medicine like Advil, and of no use for high blood pressure. A family member about 60 years old asked us to take his pressure. 170/114. Extremely high. He looked and felt well, but at that pressure, he will have problems soon enough if left untreated. We are unprepared to do anything further for this now.

Patient volumes are slowly coming down as we continue to discharge the more stable patients to Fond Parisienne, and to airlift the unstable patients mostly to Santo Domingo. We are told that the Dominican Air Force can’t fly patients to sites in Haiti as they are prohibited from overflying Haitian Air Space.

Relief agencies and government organizations are well-meaning and well-intentioned but the bureaucracy at times is disconnected from the reality of the conditions and is slowing us down. The medical teams needs to care for patients and organize the patient care infrastructure. The government and relief agencies should organize their own efforts to do the necessary administrative work of identifying and tracking refugees. For example, I am just finishing accommodating the third request today from a bureaucratic organization to generate a patient census broken down by gender, age and ward location. Our patients are relocating themselves from ward to ward, or inside to outside and bed to bed, or upstairs and downstairs at will. We eventually find them for rounds, but to specify a location for some would be ridiculous. The agency wants to know how the patients got here and how they will leave. I am being hounded for this information several times per hour even as I try to make rounds and take care of patient care-related issues. We use various artifices to try to keep them all happy as we continue rounds, but the list is completed later in the day.

4 p.m.: Three small tremors shake the orphanage, making a distinct grinding noise. The patients start screaming and make as if to run out of the building, but it is all over in less than 30 seconds. I guess they are suffering from earthquake fatigue because within a minute or two everyone is back to what they were doing, except one lone family dragging their mattress and bags outdoors. They are quickly convinced to stay inside. Nonetheless, there remains a core of about 15 families living under sheets as tents that will not move back indoors. I have to admit that after the bigger temblor a few days I was eyeing walls and roofing suspiciously. I tried to imagine what it would be like for all the building material to tumble down in an instant. The quake in Port-au-Prince was hundreds of times, maybe more, stronger. No wonder some remain terrified. The Red Cross comes by and informs me that they want their tent back to use to cover a supply shipment. It is our one decent tent in the orphanage and houses about10 patients. I put them off my saying, somewhat truthfully, that I expect a replacement tent any moment and could we please just wait for it, perhaps later in the day? They agree to come back and re-check later, but I don’t see them again, just as I had hoped.

We have learned other useful artifices. Ruth, my wife, told me that earlier in the day she met a Dominican couple that walked to the orphanage from their home in Jimaní to confide that they had taken in a Haitian woman and her child. The Haitian woman’s 5 other children and husband had all been killed in the earthquake. We have been told not to take refugees into the medical compound, only patients. “Do they have fever?” Ruth asks. “No.” “Diarrhea?” “No.” “Surely they must be itching, right?” Indeed, they saw the child scratch herself. “Splendid!” exclaims Ruth in triumph. “They have itching. That’s a medical condition and we can treat that. Bring them” They do. I had been loading a bus with patients and had it filled with 11 patients and more family members. I get one of those inexplicable orders from an oversight organization: Only ambulatory patients can board the bus now.” This message arrives just as we are trying to hoist an elderly woman with an above-the-knee amputation on board. I look at Jim Webb, the emergency medical technician from British Columbia who is overseeing getting patients down to the bus. “:Jim, you thinking what I’m thinking?” “Yup,” he says. I turn to the nurses and the new medical director who is getting oriented. “I pronounce everyone ambulatory,” I say. We all go back to loading the bus.

6 p.m.: One issue is whether the conditions at Fond Parisienne are as good as we are told. Since one picture is worth a thousand words, and since it is relatively quiet at the moment, I grab Chris Madden the neurosurgeon and tell him we should go to Fond Parisienne to judge conditions for ourselves. We head from the orphanage up to the main hospital where I arrange for a car and a driver. I have the keys in my hands and we are just about to leave when the walkie-talkie crackles to life with news that 3 doctors from here have had the same idea and have already gone to check it out. I tell Chris we would be better served by heading back to the orphanage and putting out fires.

We walk back from the main hospital and down the slightly sloping field to the orphanage. Meredith Warner, an orthopedic surgeon from Baton Rouge, grabs me and says, “Take me to see your orthopedic cases.” We quickly organize an impromptu posse to review all the patients who could potentially go back for additional surgeries. Many have had rapid surgeries to deal with the worst of their injuries. It has become clear to us over the past few days that the inundation of initial patients was so awesome, and their worst injuries so grave, that injuries that we would otherwise call fairly major had to be left for later. It is now later.

We find Donna Doue, a physical therapist from New Orleans who is leading physical therapy efforts. She has a sense for who can use limbs and who can’t. In short order we identify a new wave of incompletely attended and significant injuries. A woman with a compound fracture of her femur in a large leg cast. She is the rare patient with an X-ray, the review of which shows that the cast isn’t correctly positioned to protect the bony injury. She will need a revision. Meredith also notes that the knee on her other leg probably has torn ligaments and possibly cartilage damage. We identify a slew of additional broken bones or potentially broken on patients, dislocated joints, misaligned joints and major contusions, hematomas and assorted other injuries. Everyone has been well-attended, but not fully attended in the crunch. Meredith asks when we can expect the new X-ray machine to arrive. It was supposed to have gotten to Port-au-Prince two days ago. We understand that it has arrived there, but no one can get through the tangle of traffic there to get it back to us in Jimaní. A party of American medical students and other volunteers had left that morning to try to retrieve it.

We make a tentative operating schedule for the next morning for these new cases, based on what can be done without X-rays. I am translating Creole to English for patients and Donna, and Creole to Spanish for the Spanish team. We schedule another woman to have her pelvis examined under anesthesia. Her left leg is severely swollen for unclear reasons. She is on the side walk and every single patient as far as she can see is missing an arm or leg. She makes me promise that when she wakes up, she will still have her leg. I promise. Things are going relatively smoothly, but not without some comic relief. I tell one female patient to eat and drink nothing after midnight because she will have her fracture re-set under anesthesia the next morning. A look of panic comes into her eyes. After come confused conversation I determine that she thinks I told her that after the operation she will never be able to eat or drink again after midnight!

8 p.m.: The team that went to Port-au-Prince returns and reports that the X-ray machine remains there but no one knows why. They have brought back Champagne Cola and paté chaud, a local Haitian fast food for us to try. They bought these in Port-au-Prince, which is some evidence of re-establishment of infrastructure, but we all understand how far is left to go. A volunteer from Puerto Rico spots me and updates me on discussions with the Dominican Government. He has negotiated a protocol to transfer Haitian patients to Fond Parisienne that satisfies the Dominican Government’s reporting needs, and the UN refugee auditing needs. I shake his hand in disbelief and thank him. I have no idea what he said or how he did it, but this is great news. Tomorrow when we try to transfer the next bus of more stable patients will be the acid test.

January 26, 2010

4 a.m.: The roosters are starting to get us up. We spent last night in the home of Senator Peguero from Jimaní. After a quick breakfast in the morning we came back to work.

A new tent city smaller than the last has sprung up with about 15 families in the courtyard of the orphanage. This is in addition to the 10 patients in the official tent put up by the Red Cross. I am put in charge of Team A, in charge of caring for about 60 patients. Many people are lying around in cots indoors and outdoors (under sheets) with partial or total amputations of various limbs. Many have external fixation hardware protruding from their skin. These are small diameter rigid rods that are anchored by screws and pins bolted directly into the bones. They stick several inches out of the skin like porcupine quills. Rounding on all patients take the better part of 6 hours, partly because of so many interruptions. A young man of 26 years has a partial leg amputation. His house collapsed around him and family members were killed. A woman looked like she had been pregnant recently. We asked where the baby was and she started crying. Her 2-month-old had been killed in the quake. A dusty but spirited man had a broken leg bristling with external fixation rods, screws and bolts. After examining him, he introduced us to his wife. She was one of the patients we took to the hospital in town yesterday for the ultrasounds. He produced a small dossier, his sole possession, which was filled with pictures of his art work. He is a noted Haitian artist. Now he is an almost nameless face in a sea of human wreckage. It is hard to imagine the transformation from noted artist to dusty, injured casualty, propped against the side of the hospital.

Several babies are running very high fevers and probably have malaria, and there is no chloroquine to treat malaria.

Around 9 a.m. there is a mild aftershock that rattles the walls and ceilings. There is a burst of screaming and yelling from the patients but it blows over relatively quickly. A small stream of patients decide again to come back outdoors and I watch as mattresses are pulled through the dirt back into the middle of the courtyard.

At 10 a.m., we suddenly have to interrupt rounds because we are told that a bus will take stable patients to Fond Parisienne, an orphanage now used as a hospital just across the Haitian border, not too far away. There is much confusion trying to sort out who is stable enough for discharge and who needs to stay. Many that are able want to try to go back to Haiti.

The Dominican Public Health people come by to introduce themselves around noon and want statistics on what we are doing. We spend some time explaining our procedures and giving them on overview of the patient census. This is another diversion, but eventually we get the bus loaded and send about 91 patients plus their family members off to Fond Parisienne.

A group of physical therapists arrived. We find them making rounds and get several quick consults from them. They are doing physical therapy on rough, unlevel ground, with people in bare feet. I look around at the large number of people with amputations and with serious bony injuries now struggling to walk again. How long will it take for Haiti to recover? The lame and invalids will be constant reminders of the earthquake. Rehabilitation of limb injuries and the need for prosthetic limbs will be a consuming need for years to come.

I have seen a Haitian woman who is a patient on another team. She has been walking around with her baby. She comes over to ask me to look at it, as it has developed diarrhea. I pull back the blankets and see the he has two broken legs in two separate long and tiny plaster casts. This is the third case of infant diarrhea in the last 24 hours, and the prior 2 are fairly ill. We decide to create a diarrheal disease isolation area to help stave off a wave of illness. This is the time we expect to start seeing the wave of medical and infectious complications after the initial wave of trauma recedes.

Steve Youngers, the anesthesiologist who managed the unresponsive boy who came in yesterday evening, comes by. He reports that the boy was stable this morning and slightly improved. We never got a diagnosis. He will be choppered out later that morning along with a critically ill baby.

Around 6 p.m. I tell a colleague that things seem to be calming down. Within 15 minutes, two patients decompensate, both in the “ward” which is the sidewalk under the second floor balcony. One is a man of about 25 who has a casted broken left leg. He was stable on rounds in the morning and I spoke to him around 4 PM to see if he wanted to go on the next bus to Fond Parisienne. Now he is writhing in pain on the sidewalk, on his thin mattress, holding his belly. “Am I going to die?” he asks me in Creole. “No”, I saw. “Not today. But we have to take you to the main hospital” I respond in Creole. His wife panics and begins to wail. A crowd gathers. Somehow we manage to get an IV in him quickly, give him some morphine and get him up to surgery. His diagnosis is a mystery. I hope it is not a case of typhoid, which can sometimes look like this before the fever sets in. I make my way up to the hospital to talk to the surgeons to give them some history on this new case. I pass by intensive care and see that and the girl with the pelvic fracture from several days ago is still in a bed there, still not choppered to Santo Domingo.

January 25, 2010

9:30 a.m.: No deaths in the hospital on the past 24 hours. Census remains around 300. Today, the girl with appendicitis is stabilizing on antibiotics and intravenous fluids. A 7-week-old baby who came in late last evening with severe dehydration, electrolyte imbalances in her blood and seizures, is looking better after intensive overnight treatments, mostly done without the aid of laboratory blood tests to monitor her. The operating rooms are having difficulties due to intermittent power outages. We are trying to get patients evacuated to other hospitals with more infrastructure. Keeping parents and children together when the children get evacuated is a logistical problem. No child can be evacuated without a family member. Security remains a problem with thefts of medical equipment and supplies. The security guards may be involved in thefts. Some staff are having emotional difficulties with the stress, long work hours and sleep deprivation. There is a counselor on site, but few are availing themselves. A sense of organizational order and structure is emerging, but coordinating medical and related issues remains a challenge. Today we want to transport out the girl with a femoral head dislocation and fracture (in the hip area). If she cannot get a definitive operation, which cannot be performed here, she could have permanent hip damage worse than what she already has. There is an orphanage next door with a large number of casualties. I don’t have details yet. Two Blackhawks landed around 9:30 a.m. Perhaps we can get this girl, and some other critical patients out.

Starting around 6 p.m. a new wave of seriously ill patients arrived, including a boy of about 10 who is slipping into a coma for unclear reasons.

January 24, 2010

My wife, Ruth Berggren, is an infectious disease specialist. She was in Haiti from January 2-11. She had returned from being in Haiti and got back to San Antonio just 36 hours before the earthquake hit. She quickly reorganized and was back to help within 3 days of the earthquake. She is at Buen Samaritano Hospital in Jimaní, Dominican Republic just on the Haitian border. The hospital is a major staging ground for Haitian earthquake refugees.

I am now on my way to join her in Jimaní. I am an infectious disease doctor, though now working primarily as an oncologist. I spent the night in the Holiday Inn on Abraham Lincoln, in Santo Domingo. I am accompanied by Chris Madden, a neurosurgeon from Parkland Hospital in Dallas. A driver with the Dominican government was to get us at 10 a.m. to try to get us a ride to Jimaní, as he could no longer take us due to scheduling issues. My cousin Mayra, who is a native Dominican, got us at 8:30 a.m. and we tried the bus station but could not find a good connection to Jimaní. She called her friend with the UN who told us to come to a small, private airport on the outskirts of Santo Domingo for an immediate helicopter ride to Jimaní. We dashed out there only to find that we had to wait for a helicopter, the earliest of which could not come for several hours. Just as we hunkered down to wait, a driver said he was going to Jimaní and leaving immediately. We scrambled and were quickly in his Land Rover. He is Carlos Educar, named by CNN as one of the 10 most influential Hispanics on the Internet. He spends the entire about 6-hr trip to Jimaní talking about Dominican and Haitian history and politics and about earthquakes, culture and more. He is a wealth of detailed information. He is working with Love the Child Orphanage just over the Haitian border, and will pass through Jimaní and drop us off.

When we get to Jimaní at the Buen Samaritano Hospital, I quickly find Ruth. I try to get a place to store my gear and quickly find out there is no dedicated bed for me, or food. Not a big deal, just a small problem. My gear and personal effects are in a pile in the middle of the main room on the second and top floor of the hospital. I get a rapid orientation from the doctor on duty and get registered and signed in. My assignment changes several times over the next few hours.

At the nightly staff meeting I hear the hospital census is around 300, but the facility is designed for 20. Supplies, organization, infrastructure (reliable electrical power, water, etc.) are all issues. Wounds are crush injuries, broken bones, traumatic amputations, some burns and some other medical problems. Helicopters, including US Army Blackhawks are coming and going.

Finally I get assigned to ICU duty and join rounds in progress. Operations are running and attempts are being made to have centralized communications, command and control. Patient care looks good given the circumstances.

A young girl has had a traumatic amputation of her right arm at the shoulder with massive blood loss and a dangerously low hemoglobin of 3 (normal is 10 or more). Blood is being typed (but not crossed) and transfused. Another girl of about 10 has a dislocated left femoral head (which connects her leg to her hip) and needs to have surgery to avoid more damage, but she has to be airlifted to a bigger facility for the surgery and that is not possible now. One girl was thrown down the stairs during the earthquake and developed appendicitis. Her appendix ruptured and she developed peritonitis, a severe internal infection in the abdomen. Now there is concern she may have recurrence of infection. She is moaning and febrile. Another woman suffered severe blood loss after her surgery today to amputate a limb and is ill. There are many more patients like this. The pain and suffering has decreased dramatically in the past 48 hours thanks to the arrival of narcotics, which are being used liberally.